Some musings on germ theory

1. At the ER yesterday, I had a 9-month-old boy lean down and start chewing on my stethoscope bell while I was listening to his chest. A lot of the babies like to grab the cord of my stethoscope as I'm leaning over them and try to put that in their mouths, but I've never seen anyone just lean over and start munching hands-free. I guess he's teething; good thing I had cleaned the thing right before seeing him, or he would have gotten a mouthful of everyone else's bronchiolitis and gastroenteritis bugs.

2. I have a cough/cold, and I think it's from being coughed on last week by a baby in the ER. They're not very perceptive when it comes to not coughing in other people's faces.

3. When you go out for dim sum in Hong Kong, you get a place setting at each seat (teacup, bowl, chopsticks, spoon), two teapots, and a large bowl in the middle. One teapot has your choice of tea (and there are so many choices, yum!) and the other has hot water. You use the hot water for two things: first, to refill the tea teapot as you go (and periodically a waiter will come around and refill the water teapot for you), and second, to wash your place setting. "Wash your place setting? What do you mean!?" Well, you pour hot water in your own bowl, then swirl your cup, spoon, and chopsticks in them. When washing your chopsticks, you face a dilemma, since only about an inch or so of chopstick can be submerged in the bowl. So you can use the spoon to ladle some water onto the higher part of them if you life, or maybe use your fingers. When you're all done, you pour the dirty water from your bowl into the large bowl on the table, and the waiter takes it away.
When I was younger, my mom would make us wipe down our spoons and chopsticks when we ate at restaurants, and I thought it was dumb. Embarrassing, really. And people don't do it so much at Chinese restaurants, but everyone at Vietnamese pho noodle shops does it all the time. At pho shops, the spoons and chopsticks and napkins are all stored at the table, so I suppose it makes sense to wipe yours off before you use it, at least to get the large dust particles off.
When I went to Hong Kong with my mom a year and a half ago, my grandmother made me wash my place setting, and I went along with it because I didn't want to argue, but in my head I was thinking, "This is so dumb. It doesn't do anything." Then I looked around and, lo and behold, EVERYONE was doing it! The waitstaff EXPECTS you to do it -- that's why they bring you the large garbage-water bowl! So apparently it's a cultural thing. However, that does not mean there aren't flaws in the logic.
I highly doubt 1) that the china is *so* dirty coming out of the kitchen so as to be considered unusable without another washing; 2) that rinsing the china in boiling water for 15 seconds is going to kill anything that wasn't already dead or that wouldn't hurt you anyway; 3) that you're rinsing off any soap residue (a weak second explanation my mom offered me, but I know she didn't believe it either); 4) that you're not doing more harm than good by getting your own grubby fingers in on the action. But, whatever. When in Rome...
My grandmother adds her own twists to the procedure. Sometimes she insists that you use tea to wash the china, although I never figured out why. She also likes to use her fingers to really rub the bowl of the spoon and the food end of the chopsticks while washing them -- extra insurance against dirt, I suppose. And as a person relatively aware of germs and the standards of aseptic technique, I tend to watch out for things like holding onto a handrail and then eating finger foods without first washing your hands. So one morning this past winter break while we were in Hong Kong, I happened to notice my grandmother holding onto a handrail while we went down some steps on our way to dim sum -- she's 84, so she needs the handrail for balance -- and then when we got to the restaurant, she started washing her spoon and chopsticks with her hands and I had to say something (after speaking gibberish Cantonese myself, I got my cousin to say something for me). I'm pretty sure that it never would have occurred to my grandmother that she was making her utensils dirtier by washing them with her fingers -- that's how different her concept of sickness is from mine. I think the difference is both age and culture.
For instance, she 100% believes that being cold will lead to arthritis, which is a common misperception in the U.S. as well. Being cold is not really a good thing, so there's no real harm in people believing this. But then there's her dishwashing methods. She doesn't have a dishwasher in her apartment, so one night I helped her wash the dishes after dinner. I filled a basin holding the dirty dishes with water and used a rag and soap (it was shampoo, actually!) to wash all the bowls, spoons, and chopsticks. Then I rinsed them in running water and stacked them on the counter. My grandmother started heating a wok of water and placed the clean dishes in it -- to disinfect, I guess. In the U.S., I think we would only do this to glass baby bottles, but whatever, I go with the flow. But then she wanted me to stop using running water to rinse the dishes and only rinse them in the basin -- which you may remember was holding dirty dishes and now soapy water -- and then put them in the wok. So that would mean the wok water would be getting soapy. It didn't make sense to me, so I kept doing it my way. Water wastage, be damned. And what about cups? Cups do not get washed in my grandmother's house; then get put in a pan and boiling water gets poured over and in them, so they're "steam-cleaned." Why don't cups need soap? I have no idea, but there were four women there who had been wearing lipstick, which therefore wasn't coming off. Craziness, I know, but there's more: her kitchen doesn't have drawers, so the spoons and chopsticks are stored upright in a canister, like what I keep my cooking spoons and spatulas in at my house. When they're not being used, you have to place a dishcloth over them (to keep off dust? germs? ghosts? who knows...), BUT it's the same dishcloth that has been used to clean the dishes and wipe down the counter and all that other stuff, just rinsed off and wrung out. To me, that's gross. (However, I know there are plenty of people in this country who will use a nasty nasty sponge for months on end to wash their dishes. ick!)

So maybe I'm a little hyper-sensitive to my grandmother's quirks; I *was* a microbiology major, after all. And I know I shouldn't be too harsh, because I certainly have my own quirks as well (I won't share, don't worry). But it has made me wonder about germ theory. In 1854, it was a breakthrough when John Snow took the handle off of the Broad Street (London) water pump and people living nearby stopped getting cholera. In the 1840s, Ignaz Semmelweis was ostracized for recommending that surgeons wash their hands in between performing autopsies and delivering babies (the nerve!) -- this is how ignorant of the germ theory of disease people were 150 years ago. We know more now, but we don't always put our knowledge into practice (ahem, grimy sponges and not washing your hands).

On the other hand, there are schools of thought that say using antiseptic -- or worse, antibiotic -- products are doing more harm than good. 1) antiseptic/antibiotic hand gels kill the commensal bacteria that naturally live on our hands, leaving room for bad bacteria we come in contact with to set up shop (bacteria generally don't grow on top of one another, so if the good bacteria are there, there won't be room for the bad ones). 2) antibiotic hand gels and soaps are worse because they are allowing both good and bad bacteria to grow under the selective pressure of an antibiotic, thus promotigng antibiotic resistance (this is a concern, but no one has really shown that it might actually be a possibility). 3) some say that children who grow up in sterile homes that are constantly being wiped down with disinfectant wipes and sprays are at risk for actually being sicker, because their immune systems have never had to set up primary defenses against common household allergens and microbes, and as long as you're not talking about something like cholera or H. pylori, your gut can handle pretty much anything you ingest and you won't get sick anyway. So housewives (and househusbands!), stop sterilizing those counters!

So what's the solution? Too dirty = not good. Too clean = not good. Maybe it's all in your frame of reference. It is important to remember, after all, that the majority of us (medical students and professionals, take note that I am talking about home habits, not clinical habits) are not going to be coming into contact with microorganisms that cause really severe diseases, so you can afford to be a little bit dirty. And I suppose there's no harm in consuming soap residue from your dishes. Just take my advice and don't get too close to coughing babies.